Yes. Each practitioner privileged through the medical staff process is expected to participate in hospital-sponsored continuing education (see MS.12.01.01). Such education is based on performance improvement^ activities that focus, at least in part, on the nature of care, treatment, and services offered by the hospital. The organized medical staff, then, determines the curriculum and prioritizes the time frames for completion.
The organized medical staff also determines participation requirements, such as required hours or activities to be completed, the time frame for completing (e.g., annually, each reappointment cycle, etc.), and how participation is documented. Participation is also considered in decisions about reappointment to medical staff membership or renewal/revisions of individual clinical privileges.
Additional examples of hospital-sponsored education requirements for privileged practitioners may be found at:
^See also MS.05.01.01 and MS.05.01.03.
The organization's accreditation coordinator has access to the manual containing the full text of the standards referenced.
Manual: Hospital and Hospital Clinics Chapter: Medical Staff MSNew or updated requirements last added: February 16, 2022. New or updated requirements may be based on revisions to current accreditation requirements, regulatory changes, and/or an updated interpretation in response to industry changes. Substantive changes to accreditation requirements are also published in the Perspective Newsletter that is available to all Joint Commission accredited organizations.
Last reviewed by Standards Interpretation: February 16, 2022 Represents the most recent date that the FAQ was reviewed (e.g. annual review).
This page was last updated on February 16, 2022 with update notes of: Reflects new or updated requirements Types of changes and an explanation of change type: Editorial changes only: Format changes only. No changes to content. | Review only, FAQ is current: Periodic review completed, no changes to content. | Reflects new or updated requirements: Changes represent new or revised requirements.